US4591086A - Surgical stapling instrument - Google Patents

Surgical stapling instrument Download PDF

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Publication number
US4591086A
US4591086A US06459081 US45908183A US4591086A US 4591086 A US4591086 A US 4591086A US 06459081 US06459081 US 06459081 US 45908183 A US45908183 A US 45908183A US 4591086 A US4591086 A US 4591086A
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Prior art keywords
track
staple
trigger
instrument
means
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Legal status (The legal status is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the status listed.)
Expired - Lifetime
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US06459081
Inventor
Jay E. Campbell
Richard H. Reichmann
Lehmann K. Li
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Covidien AG
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Wyeth Holdings LLC
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    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61BDIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B17/00Surgical instruments, devices or methods, e.g. tourniquets
    • A61B17/068Surgical staplers, e.g. containing multiple staples or clamps
    • A61B17/0682Surgical staplers, e.g. containing multiple staples or clamps for applying U-shaped staples or clamps, e.g. without a forming anvil
    • A61B17/0684Surgical staplers, e.g. containing multiple staples or clamps for applying U-shaped staples or clamps, e.g. without a forming anvil having a forming anvil staying above the tissue during stapling

Abstract

A surgical stapling instrument is disclosed. The instrument has a handle, a trigger, means for carrying a staple, the carrying means comprising a track for containing at least one staple, and means for closing the staple. The improvement to the track comprises a leaf spring. The track and the leaf spring are a unitary element. The leaf spring is at the end of the track adjacent to the closing means. In one embodiment, the closing means is an anvil surface terminating in a flange.

Description

CROSS REFERENCE TO RELATED APPLICATIONS

This is a continuation application of U.S. Application Ser. No. 191,654 filed Sept. 26, 1980, now U.S. Pat. No. 4,406,392, which is a continuation-in-part application of U.S. Application Ser. No. 153,228, filed May 27, 1980, now abandoned.

BACKGROUND OF THE INVENTION

This invention relates to a surgical skin/fascia stapling instrument which contains a plurality of staples and which allows a single staple to be formed and removed from the instrument.

To develop the background of the invention and to establish the state of the art, the following references are cited: U.S. Pat. Nos. 4,179,057; 4,109,844; and 3,873,016, which are incorporated by reference. These references disclose stapling instruments which contain a plurality of staples and from which a single staple can be formed and removed.

The stapling instrument of this invention has advantages over these prior art references. One advantage is the relative size of the instrument which is maintained while the number of mechanical parts is decreased. Therefore, as a general statement, the ease of operation and the reliability of the instrument is improved. The operation and reliability of an instrument can be critical in the surgical operating area where even seconds may determine if a surgical operation or procedure is a success. Another advantage is the orientation of the flange on the anvil surface. The flange orientation is opposite to the direction of stapling. For most surgeons, the natural direction of stapling is always away from their body. The orientation of the flange allows the surgeon to advance the instrument and remove the formed staple in a direction away from the body. This has still another advantage in that while stapling the surgeon cannot accidentally brush against the open wound site.

Still another advantage of this instrument is the stapling indicator which is on top of the handle. The instrument thus does not have to be turned over to determine the number of staples remaining in the instrument. Still further, another advantage is the location of the trigger means which are internal to the handle. This seems to provide a more sterile environment and to prevent or decrease the liklihood of pinching a finger or fingers during use. Yet another advantage is the configuration of the instrument. In many surgical procedures, the instrument configuration may give a better field of vision of the wound site to the surgeon.

The surgical stapling control means also had advantages over the prior art references. The control means prevents the trigger from returning to its initial position if the compression is interrupted. Thus has the advantage of preventing a second staple from being formed on the anvil flange before a first staple is separated from the instrument. Another advantage of the control means is interrupted stapling. The surgeon can now stop the compression of the trigger into the handle to realign the instrument over the wound site. Thus the possibility of a perfect stapling procedure is greatly enhanced.

SUMMARY OF THE INVENTION

A surgical stapling instrument comprising a handle and a trigger pivotally attached and on compression internal to the handle has now been invented. The forward portion of the handle contains a track; a plurality of staples loaded and staple advancing means carried on the track; a track cover mounted on the track; an anvil surface mounted and a first bias means movably mounted on the cover, the anvil surface terminating in a perpendicular flange; a staple adjacent the anvil surface; and a retainer spring mounted on the anvil surface and separating the staple from the flange.

The forward portion of the handle also contains a guide block which is mounted on the track cover adjacent the anvil surface.

A forming blade and a second bias means are movably mounted on the guide block, the forming blade and the trigger having coordinating surfaces.

On compressing the trigger into the handle, the forming blade pushes the staple downward, the staple displaces the retainer spring, the staple forms on the flange and the retainer spring moves back to its initial position. On releasing the trigger and advancing the instrument the formed staple is separated from the flange, the second bias means returns the trigger and the forming blade to their initial positions, and the first bias means activates the staple advancing means to place the forwardmost staple adjacent the anvil surface.

An alternative surgical stapling instrument comprising a handle and a trigger pivotally attached and on compression internal to said handle has also been invented. The forward portion of the handle contains: a track; a leaf spring on the terminal end of said track; a plurality of staples loaded and staple advancing means carried on said track; a track cover mounted on said track; an anvil surface mounted and a first bias means movably mounted on the cover, the said anvil surface terminating in a perpendicular flange; and a staple adjacent said anvil surface separated from said flange by said leaf spring.

The forward portion of the handle also contains a guide block which is mounted on the track cover adjacent the anvil surface.

A forming blade and a second bias means are movably mounted on the guide block, the forming blade and the trigger having coordinating surfaces.

On compressing the trigger into the handle, the forming blade pushes the staple downward, the staple displaces the leaf spring, the leaf spring moves back to its initial position and the staple forms on the flange. On releasing the trigger and advancing the instrument, the formed staple is separated from the flange, the second bias means returns the trigger and the forming blade to their initial positions, and the first bias means activates the staple advancing means to place the forwardmost staple adjacent the anvil surface.

In one embodiment the stapling instrument described above comprises a track cover adjacent the forward portion of the trigger. In another embodiment the stapling instrument comprises the forming blade located between the forward portion of the track cover and the anvil surface.

In yet another embodiment the stapling instrument described above comprises an indicator to indicate the number of staples remaining in the instrument. The indicator has an initial end visible in the handle. A terminal end is movably mounted on the staple advancing means such taht on releasing the trigger, the first bias means pulls the terminal end and thus moves the initial end of the indicator.

A method of using the stapling instrument is within the scope of this invention.

A method of closing a wound or of connecting skin or fascia comprises: joining the adjacent edges of the wound or skin or fascia; placing the stapling instrument described above adjacent to the wound or to the skin or fascia; compressing the trigger into the handle; and releasing the trigger and advancing the instrument, whereby a formed staple is placed between the edges.

DESCRIPTION OF THE DRAWINGS

FIGS. 1 and 2 are side and top views respectively of the stapling instrument;

FIG. 3 is a broken perspective view of the front portion of the instrument shown in FIGS. 1 and 2;

FIGS. 4A and 4B are perspective views showing the parts of the stapling instrument control means in the handle and in the handle cover, respectively;

FIG. 5 is a broken sectional view of the stapling instrument control means;

FIG. 6 is a perspective view of the instrument trigger, and an expanded view of the track and track cover;

FIGS. 7 and 8 are sectional side, and top views respectively of the instrument track cover;

FIGS. 9 and 10 are sectional side, and top views respectively of the instrument track;

FIG. 11 is an expanded view showing the relationship of the forming blade, bending anvil and retainer spring; and

FIGS. 12 and 13 are broken and sectional side views of FIG. 1 showing the position and relationship of the staple and retainer spring in the initial position and on compressing the instrument trigger;

FIGS. 14 to 16 are broken rear views of the bending anvil showing the relationship of the staple, forming blade, retainer spring and anvil flange during compression of the instrument trigger;

FIG. 17 is an expanded view showing the relationship of the forming blade, first bias means, guide block, track cover, bending anvil and retainer spring.

FIGS. 18A and 18B are perspective views showing an alternative embodiment of the stapling instrument control means;

FIG. 19 is a broken sectional view of the alternative stapling instrument control means of FIG. 18;

FIG. 20 is a broken perspective view of the alterative control means in the trigger;

FIG. 21 is an expanded view of an alternative embodiment of the track and track cover;

FIGS. 22 and 23 are broken sectional side and top views, respectively of the instrument track shown in FIG. 21;

FIG. 24 is an expanded view showing the relationship of the forming blade, bending anvil and leaf spring shown in FIG. 21; and

FIGS. 25 to 27 are broken and sectional side views showing respectively the positon and relationship of the staple and leaf spring in the initial position, on partial compressing and on complete compressing of the instrument trigger.

DESCRIPTION OF THE PREFERRED EMBODIMENT

Referring to FIGS. 1 to 3, the instrument comprises a handle 1 and a trigger 2. A staple 10 (more fully described in FIGS. 6 and 9 to 10) is inserted and attached to the forward portion of the handle 1, for example by cementing or sonic welding. The initial end of an indicator 13 is visible through an opening in the forward top portion of the handle 1. A combined ratchet stop and cover 14 (more fully described in FIGS. 4 and 5) is attached to the rear portion of handle 1.

Referring to FIGS. 6 to 11 and 17, the track cover 3 is assembled as follows. The first bias means 7, which preferably is a negatory spring, is mounted into the openings 3a in track cover 3. Retainer spring 15 is inserted onto bending anvil retainer tabs 9a. The bending anvil 9 and the retainer spring 15 are then placed through the opening 3b. The terminal end 13a of indicator 13 is mounted onto the track cover 3 in front of the spring 7 and protrudes through the bottom 3c of the track cover 3.

The guide block 4 is mounted under tabs 3d. A locking wedge 8 is then pushed into slots 3e to hold the guide block 4 on the track cover 3. Other means for holding the guide block on the track cover can be used, for example bonding, riveting, peening, tacking or welding.

The second bias means 6, preferably a spring, is inserted into the guide block opening 4a. The forming blade 5 is mounted through the guides 4b in the guide block. The vertical surface of the forming blade 5 is between the forward portion of the track cover 3 and the anvil surface 9.

Referring specifically to FIGS. 9 and 10, staples 12 are loaded onto the track 10. The staple advancing means, preferably a staple pusher 11 is carried on the track 10 behind the staples 12 by the first bias means 7 (shown e.g., in FIG. 8). The indicator 13 is carried with the staple pusher 11 by the first bias means 7. The staples 12 in FIGS. 9 and 10 are shown in their orientation when the instrument is in the position shown in FIG. 1.

The track cover 3 is then mounted onto the track 10 for example by sonic welding. The spring 7 is then attached to the advancing means tab 11a by pulling back on the indicator 13 and engaging the center of the extended spring 7 with the advancing means tab 11a. The trigger pivots 2a are places against stops in the forward portion of the handle 1. The track cover 3 and track 10 are then inserted and attached to the forward portion of the handle 1, for example by cementing or sonic welding. The trigger pivots 2a are thus captured.

Referring to FIGS. 12 to 17, the stapling instrument is used by placing the anvil surface 9 adjacent a wound opening or between skin or fascia. The trigger 2 is then compressed into the handle 1 (shown in FIG. 1). The front end of trigger 2 engages the top flange of forming blade 5, forcing it down thru the guides 4b on guide block 4. The lower edges of the forming blade have a recessed area to engage staple 12. The staple is pushed downward and forced to bend at right angles on either side of the lower flange of anvil 9.

In the initial or rest position, the staple 12 is adjacent the vertical surface of the anvil 9, as shown in FIG. 12. The forming blade 5 lowers and pushes the staple downward and onto the anvil flange. The forming of the staple around the anvil lower flange is well known in prior art, e.g., as described in U.S. Pat. No. 4,014,492 issued Mar. 29, 1977 which is incorporated herein by reference. By releasing the trigger and advancing the instrument, the staple 12 is separated from the anvil flange.

When releasing trigger 2, spring 6 returns forming blade 5 and trigger 2 to their relaxed positions. Spring 7 pulls against pusher 11 to advance the plurality of staples. Each time trigger 2 is compressed indicator 13 advances with pusher 11. An indication of the staple depletion appears in the opening in the top forward portion of handle 1.

Referring to FIGS. 4 and 5, to prevent partially compressing the trigger 2, partially forming a staple 12, and then allowing the trigger to return and pick up the next staple, a multi-toothed ratchet 2a is built into the rear of the trigger 2 and cam guides 1b into handle 1. When the trigger 2 is compressed, the ratchet 2a engages stop 14a and prevents the trigger from returning to its relaxed position. The trigger must be compressed past the last ratchet tooth 2a and must be completely closed so that the guide pins 2b (more fully shown in FIG. 6) move up and cross over the cam guides 1b.

The guide pins are spring loaded. Thus when the trigger is completely compressed, the guide pins cross over the top of the cam guides 1b. On releasing the trigger from a final compression, the ratchet is thus prevented from locking on the stop 14a.

Referring to FIGS. 18 and 19 showing an alternative embodiment of the stapling instrument control means, to prevent partially compressing the trigger 2, partially forming a staple 12, and then allowing the trigger to return and pick up the next staple, a multi-toothed ratchet 16a is built into the cover 16. A stop 2c is built into the trigger 2. Cam guides 1b are built into handle 1. When the trigger 2 is compressed, the ratchet 16a engages stop 2c and prevents the trigger from returning to its relaxed position. The trigger must be compressed past the last ratchet tooth 16a and must be completely closed so that the guide pins 2b (more fully shown in FIG. 6) move up and cross over the cam guides 1b.

The guide pins 2b are spring loaded. Thus when the trigger is completely compressed, the guide pins cross over the top of the cam guides 1b. On releasing the trigger from a final compression, the ratchet is thus prevented from locking on the stop 2c.

Referring to FIGS. 20 and 21 which show respectively, the alternative control means in the trigger and an alternative embodiment of the track and track cover, the track cover 3 is assembled as follows. The forward portion of the track cover is identical to that shown in FIGS. 6 to 8. The bias means 7 (not shown) and the bending anvil 9 are mounted identically to the description in FIGS. 6 to 8 and 17. The front tabs 10a on the track 10 pass through the slots 9a and then fold onto the bending anvil 9. As shown more fully in FIG. 24, the front tabs 10a and the slots 9a are sufficiently wide to allow the forming blade 5 to move. The terminal end 13a of indicator 13 (not shown) is mounted identically to the description in FIGS. 6 to 10.

The guide block 4 is mounted under tabs 3d as shown in FIGS. 6 to 8 and 17. Blocks 3f are adjacent slots 3h on the track cover 3. Blocks 3f diagonally support the guide block 4 on the track cover 3. Forward vertical tabs 10b on the track 10 pass through the forward openings 3g in the track cover 3 and then fold onto the portion of the guide block 4 in slots 3h to hold the guide block on the track cover. Rear vertical tabs 10b pass through the rear openings 3g and then fold onto the track cover 3.

The second bias means 6 and the forming blade 5 are mounted identically to the description in FIGS. 6 & 17.

FIGS. 22 and 23 show an alternative embodiment of the track 10. In the alternative embodiment, the track 10 contains a leaf spring 10c on the terminal end of the track. The leaf spring separates the staple adjacent to the anvil surface from the anvil flange. The staples 12, staple advancing means 11, and indicator 13 are carried on the track 10 and are identical to the description in FIGS. 9 and 10. Referring to FIGS. 22 to 27, the stapling instrument with the alternative embodiments is used by placing the anvil surface 9 adjacent a wound opening or between skin or fascia. The trigger 2 (shown in FIG. 1) is then compressed into the handle 1. The front end of trigger 2 engages the top flange of forming blade 5, forcing it down thru the guides 4b (shown in FIG. 17) on guide block 4. The lower edges of the forming blade have a recessed area to engage staple 12. The staple is pushed downward and displaces the leaf spring 10c. The leaf spring 10c then moves back to its initial position to hold the next staple at the terminal end of track 10 and adjacent the anvil surface. The forming blade 5 continues to engage staple 12 which is then forced to bend at right angles on either side of the lower flange of anvil 9.

In the initial or rest position, the staple 12 is adjacent the vertical surface of the anvil 9, as shown in FIG. 25. The forming blade 5 lowers and pushes the staple downward and onto the anvil flange. By releasing the trigger and advancing the instrument, the staple 12 is separated from the anvil flange.

Claims (3)

We claim:
1. A surgical stapling instrument comprising: a handle; a movable trigger mounted on said handle; means connected to said handle for forming and driving a staple, said means comprising a movable forming and driving blade and a staple forming anvil; means for carrying a plurality of staples and presenting them to said forming blade to be driven and formed, said carrying means comprising a one piece track; a plurality of staples carried on said track with the proximal staple of said plurality being adjacent said anvil; the improvement comprising a leaf spring which is a unitary part of said track and positioned at the end of said track adjacent said anvil whereby said proximal staple is biased away from said anvil by said leaf spring.
2. An instrument of claim 1 wherein said carrying means comprises means for advancing a staple to a position adjacent said leaf spring.
3. An instrument of claim 1 wherein a portion of said leaf spring extends beyond said track.
US06459081 1980-05-27 1983-01-19 Surgical stapling instrument Expired - Lifetime US4591086A (en)

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US06191654 US4406392A (en) 1980-05-27 1980-09-26 Surgical stapling instrument
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Cited By (37)

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US4662555A (en) * 1986-03-11 1987-05-05 Edward Weck & Company, Inc. Surgical stapler
DE3713830A1 (en) * 1987-04-24 1988-12-22 Frimberger Erintrud Clamping device for closure of a wound with clips
US4811886A (en) * 1988-02-18 1989-03-14 Ethicon, Inc. Staple positioning tab
US4813586A (en) * 1986-05-07 1989-03-21 Helmut Diener Suture clip tongs
US4869243A (en) * 1988-02-26 1989-09-26 Huene Donald R Device and method for joining fractured bones
US5038991A (en) * 1989-12-21 1991-08-13 Edward Weck Incorporated Surgical stapler
US5251801A (en) * 1991-08-05 1993-10-12 Edward Weck Incorporated Surgical stapler
US5258010A (en) * 1991-05-30 1993-11-02 United States Surgical Corporation Anvilless surgical apparatus for applying surgical fasteners
US5289963A (en) * 1991-10-18 1994-03-01 United States Surgical Corporation Apparatus and method for applying surgical staples to attach an object to body tissue
US5337937A (en) * 1991-10-18 1994-08-16 United States Surgical Corporation Surgical stapling apparatus
US5356064A (en) * 1991-10-18 1994-10-18 United States Surgical Corporation Apparatus and method for applying surgical staples to attach an object to body tissue
US5366134A (en) * 1991-10-18 1994-11-22 United States Surgical Corporation Surgical fastening apparatus
US5389102A (en) * 1990-09-13 1995-02-14 United States Surgical Corporation Apparatus and method for subcuticular stapling of body tissue
US5392978A (en) * 1991-02-08 1995-02-28 United States Surgical Corporation Surgical staple and endoscopic stapler
US5427298A (en) * 1993-10-28 1995-06-27 Tegtmeier; C. Allen Method and apparatus for indicating quantity of fasteners in a fastening device
US5441191A (en) * 1993-12-30 1995-08-15 Linden; Gerald E. Indicating "staples low" in a paper stapler
US5497933A (en) * 1991-10-18 1996-03-12 United States Surgical Corporation Apparatus and method for applying surgical staples to attach an object to body tissue
US5507425A (en) * 1990-11-19 1996-04-16 Acco-Rexel Group Services Plc Stapling machine
US5560532A (en) * 1993-10-08 1996-10-01 United States Surgical Corporation Apparatus and method for applying surgical staples to body tissue
US5564615A (en) * 1992-10-09 1996-10-15 Ethicon, Inc. Surgical instrument
US5626587A (en) * 1992-10-09 1997-05-06 Ethicon Endo-Surgery, Inc. Method for operating a surgical instrument
US5662662A (en) * 1992-10-09 1997-09-02 Ethicon Endo-Surgery, Inc. Surgical instrument and method
US5762255A (en) * 1996-02-20 1998-06-09 Richard-Allan Medical Industries, Inc. Surgical instrument with improvement safety lockout mechanisms
US5908149A (en) * 1997-03-12 1999-06-01 Ethicon Endo-Surgery, Inc. Skin stapler with multi-directional release mechanism
US5938101A (en) * 1997-05-14 1999-08-17 Ethicon Endo-Surgery, Inc. Skin stapler with movable anvil
US5937951A (en) * 1997-07-18 1999-08-17 Ethicon Endo-Surgery, Inc. Skin stapler with rack and pinion staple feed mechanism
US6446854B1 (en) 1991-10-18 2002-09-10 United States Surgical Corporation Surgical stapling apparatus
US6601748B1 (en) * 2001-12-15 2003-08-05 Modern Medical Equip. Mfg., Ltd. Surgical stapler
US20030222118A1 (en) * 2002-05-28 2003-12-04 Temedco, Ltd. Surgical stapling device
US6666872B2 (en) 2000-04-11 2003-12-23 United States Surgical Single shot meniscal repair device
US20050033317A1 (en) * 2003-07-11 2005-02-10 Ables Claudette M. "Staple align", medical skin stapler with attached skin tissue forceps
US20050116008A1 (en) * 2002-08-29 2005-06-02 Thornton Curtis W. Surgical stapler with removable staple cartridge
US20060016847A1 (en) * 2004-07-23 2006-01-26 Acco Brands, Inc. Low staple indicator for a stapler
US20060243774A1 (en) * 2005-04-28 2006-11-02 Kanji Matsutani Medical stapler
US7395955B2 (en) 2006-01-06 2008-07-08 Staples The Office Superstore, Llc Stapler
US7540400B2 (en) 2006-01-06 2009-06-02 Staples The Office Superstore, Llc Stapler having a moveable strike plate with lockout mechanism
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Cited By (63)

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Publication number Priority date Publication date Assignee Title
US4662555A (en) * 1986-03-11 1987-05-05 Edward Weck & Company, Inc. Surgical stapler
US4813586A (en) * 1986-05-07 1989-03-21 Helmut Diener Suture clip tongs
DE3713830A1 (en) * 1987-04-24 1988-12-22 Frimberger Erintrud Clamping device for closure of a wound with clips
US4811886A (en) * 1988-02-18 1989-03-14 Ethicon, Inc. Staple positioning tab
US4869243A (en) * 1988-02-26 1989-09-26 Huene Donald R Device and method for joining fractured bones
US5038991A (en) * 1989-12-21 1991-08-13 Edward Weck Incorporated Surgical stapler
US5389102A (en) * 1990-09-13 1995-02-14 United States Surgical Corporation Apparatus and method for subcuticular stapling of body tissue
US5573541A (en) * 1990-09-13 1996-11-12 United States Surgical Corporation Apparatus and method for subcuticular stapling of body tissue
US5507425A (en) * 1990-11-19 1996-04-16 Acco-Rexel Group Services Plc Stapling machine
US5392978A (en) * 1991-02-08 1995-02-28 United States Surgical Corporation Surgical staple and endoscopic stapler
US5258010A (en) * 1991-05-30 1993-11-02 United States Surgical Corporation Anvilless surgical apparatus for applying surgical fasteners
US5251801A (en) * 1991-08-05 1993-10-12 Edward Weck Incorporated Surgical stapler
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US5356064A (en) * 1991-10-18 1994-10-18 United States Surgical Corporation Apparatus and method for applying surgical staples to attach an object to body tissue
US5337937A (en) * 1991-10-18 1994-08-16 United States Surgical Corporation Surgical stapling apparatus
US7624903B2 (en) 1991-10-18 2009-12-01 Green David T Apparatus for applying surgical fastners to body tissue
US20090308908A1 (en) * 1991-10-18 2009-12-17 United States Surgical Corporation Apparatus for applying surgical fasteners to body tissue
US5497933A (en) * 1991-10-18 1996-03-12 United States Surgical Corporation Apparatus and method for applying surgical staples to attach an object to body tissue
US5289963A (en) * 1991-10-18 1994-03-01 United States Surgical Corporation Apparatus and method for applying surgical staples to attach an object to body tissue
US20090314820A1 (en) * 1991-10-18 2009-12-24 United States Surgical Corporation Apparatus for applying surgical fasteners to body tissue
US20090105535A1 (en) * 1991-10-18 2009-04-23 Green David T Apparatus for applying surgical fasteners to body tissue
US5366134A (en) * 1991-10-18 1994-11-22 United States Surgical Corporation Surgical fastening apparatus
US7681772B2 (en) 1991-10-18 2010-03-23 Green David T Apparatus for applying surgical fasteners to body tissue
US6446854B1 (en) 1991-10-18 2002-09-10 United States Surgical Corporation Surgical stapling apparatus
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